Guest Blog By: Tamara Kasper, MS, CCC-SLP, BCBA, LBA, Lina Slim, PhD, BCBA-D,
CCC-SLP, and Lilith Reuter-Yuill, PhD, CCC-SLP, BCBA-D, LBA
Why Collaborate?
As dually certified Speech-Language Pathologists (SLPs) and Board Certified Behavior Analysts (BCBAs), we have experienced every type of collaborative situation you can imagine, from horrific to heavenly, cringeworthy to creative, and ill-mannered to ideal. We have waded through collaborative quagmires with legal, financial, and professional issues complicating an already delicate process. We learned—the way BCBAs/SLPs learn—through research, reinforcement contingencies, direct instruction, modeling, mentoring, and yes, a little punishment, that collaboration between BCBAs and SLPs can be an electric, innovative experience that benefits the client, other team members, and you.
Documented benefits of collaboration include increased team member satisfaction (Junger et al., 2007; Wilson, et al., 2004), improved professional knowledge and skills (Caron & McLaughlin, 2002; Heron & Harris, 2001; Hunt et al., 2004) and improved outcomes for individuals with disabilities (Hunt et al., 2003). The goal of this blog is to provide you with a practical roadmap and guidelines to carefully and confidently navigate an uneven and sometimes weed-ridden terrain where successful interprofessional collaboration paves a new road to achievement.
Our Code of Ethics as behavior analysts (e.g., Behavior Analysis Certification Board, 2020: codes 1.02 Boundaries of Competence, 2.01 Accepting Clients, 2.03 Consultation, and 2.10 Collaboration with Colleagues) compel interprofessional collaboration with SLPs when we serve individuals with complex communication needs. Speech-language pathologists follow a similar code, including ASHA Principle of Ethics 1V, which dictates maintaining collaborative and harmonious interprofessional (cross-discipline) and intraprofessional (within the same discipline) relationships. We recognize the practical barriers that BCBAs and SLPs face to realizing this idyllic interprofessional fantasy world. For example, behavior analysts report little to no academic training or professional development opportunities to learn to successfully work with professionals from outside the field (Kelly & Tincani, 2013; Slim & Reuter-Yuill, 2021). Additionally, new graduates congratulated in the academy for their conceptually systematic analysis and well-defined transfer of stimulus control procedures may be concerned that replacing the verbal operants with everyday language may compromise their ability to stay true to the science or compromise their professional integrity. We might even think that if we remain open to individualization or innovation, we are no longer “being” behavioral, evidence-based, technological, or a good behavior analyst. We hear you. But here’s the deal – adopting a common goal of clear communication with the shared value that the client and their caregiver(s) are the most important individuals in the room, grants us freedom to explore individualized options that remain true to the science while respecting other professionals, and most importantly, our client. In essence, if a procedure can be interpreted behaviorally and the efficacy of the procedure can be observed and measured, we may not need to fritter over different terminology and ideologies. Function over form, my friends. We give you permission to prioritize being clinically effective over needing approval from others that you are conceptually systematic or ‘right.’
Our Collective Experience with Collaboration
As dually certified practitioners, we have the unique experience of being a BCBA and SLP within the same skin. This dual perspective has provided opportunities to integrate research and procedures from both fields, yielding inspiring outcomes. Our desire for you and your clients to share these enriched experiences drives us to offer some general guidelines and recommendations based on the available research to promote harmonious and effective interprofessional collaboration.
According to Cox (2012) a functional interdisciplinary model allows for maximal communication, shared goals and objectives, frequent updates on progress among professionals, joint problem-solving, and collective progress evaluation. He emphasizes establishing a foundation of shared ethics and mission, combined with respect for the unique expertise that each discipline brings, fostering effective collaboration and ultimately promoting enhanced outcomes. As part of the evaluation and treatment process for funders, treatment plans are exchanged. Before reaching out to contacting other professionals for collaboration, it is crucial that you thoroughly review their treatment plans and obtain information about recent sessions and progress.
So how do we do it? How do we DO this interprofessional collaboration? There are many different ways that interprofessional collaboration can occur, but there are known practical barriers for clinicians that work in settings that are funded by third party payers. We provide a fictional scenario of an area where you likely have some control – meetings! We hope that our characters Kit (child), Pat (parent), Bea (BCBA), and Sam (SLP) illustrate how you too can use our Applied Model of Interprofessional Collaboration – Meetings (AMIC-M) to set the stage for success at your next collaboration meeting!
Follow this fictional collaborative team to learn to implement the thirteen steps of AMIC-M (AMIC-M Checklist). It all starts with an invitation to collaborate. You can do this!
The parent, Pat, was concerned that Kit could not be understood by others and the BCBA, Bea, agreed. During a family treatment guidance meeting, Bea and Pat draft an email to Sam, the SLP, requesting and setting the tone for a collaborative meeting focused on improving intelligibility. To address genuine issues of time and reimbursement, all agree to work together to alternate billing to enable collaboration in Kit’s best interests.
Does the Team Agree on Why We are Here?
#1 Does the team agree that all members are present and prepared?
Arrive early and prepared to share your knowledge, experiences, and data. If the meeting is virtual, prepare a few slides that illustrate the information that will enhance collaboration in a clear, jargon-free manner (Critchfield et al., 2017). Collaboration requires an open, growth-oriented mindset. A growth-oriented mindset values collaboration and innovation to embrace challenges, seek feedback, and admit errors (Dweck, 2016). Teaming with a collaborative, growth-oriented mindset involves group members working closely and finding synergy because a team is more powerful than the sum of the individuals (Ng., 2018, 2018).
Take time to Reflect.
Bea takes 5 min to review the meeting goal. She reflects on the uniqueness of Kit as a magical, playful, lover of animals. Bea taps into lingering reinforcing effects of a previous successful collaboration experience to stay calm, confident, curious, and receptive to innovative ideas.
Establish rapport by engaging in active listening.
Bea greets everyone and demonstrates enthusiasm for the collaborative process by “rowing her OARS.” All arrived prepared, but if this was not the case, they were willing to reschedule.
OARS
O – Open Ended Questions “Tell me more …”
A – Affirmations “I see your effort …”
R – Reflective Listening “This is important to you …”
S – Summary Reflections “I heard you say …”
#2 Does the team agree on shared values and collaboration guidelines?
Cox (2019) emphasizes the importance of shared values and ethical codes in navigation of areas of agreement and disagreement. He recommends establishing an Interprofessional Collaboration Process and Guidelines (2012). Sample guidelines and a fillable template are provided and can be individualized by your team. If agreement cannot be obtained from all group members on these core values, team expectations, these should be clarified until agreement is met. If there is a general lack of agreement on the goals of collaboration, it advisable to adjourn the meeting. Addressing organizational-level problem solving may become necessary or, alternatively, the client/caregiver may need to explore alternative service providers.
Bea, as collaboration initiator, is logically the meeting leader. She reiterates the general guidelines of the process map implied in the contact letter, “One of the values of our company is interprofessional collaboration. We focus on the client and caregiver, respect each other and our roles, and avoid using jargon so that we can communicate as clearly as possible. We both have ethical codes that we need to abide by, and part of that code is that we collaborate harmoniously. If we reach a conflict, we can remind ourselves of our mutual goal of helping Kit. If needed we can put a concern in the parking lot and return to it later, when we have had a chance to reflect or gather more information. Do these general guidelines make sense to you? Is this something that you could get behind?”
If the team agrees, the collaboration meeting can move forward. If not, clarify team expectations.
#3 Does the team agree on a written meeting focus?
Ensure that team members agree on the meeting focus. Meeting purposes range from collaborating to address a specific dangerous or learning interfering behavior; collaborating regarding AAC assessment, modality selection and teaching strategies; conducting a routine progress review or Individual Education Plan meeting with the aim of establishing group goals and procedures. Establishing and writing down the group goal(s) will assist all team members in keeping the goal for the client, their caregiver(s), and team paramount. Should the group fail to reach consensus, conflict resolution strategies should be employed.
Conflict Resolution Strategies
Reframe conflict around shared values and ethics.
Reflect on perspectives and rationale of all team members.
Bring the focus back to the needs and strengths of the child.
Use evidence to inform the discussion.
Be willing to reconvene or table an issue if emotions are high.
Brown et al., 2015; Cox, 2019; Kasper et al. 2023
For our scenario, all agree on improving intelligibility as the meeting focus and this is recorded.
#4 Does the team agree on the roles and responsibilities assigned?
Key to interprofessional collaboration: Understanding of the roles and responsibilities of all team members combined with a willingness to be flexible around role boundaries communicating effectively and treating one another with respect regardless of professional title or position; staying action orientated (Kester, 2018; Slim et al., 2021; Spencer et al., 2020). Should the group fail to reach consensus, conflict resolution strategies should be employed.
In our scenario, members clarify roles, responsibilities, and areas of expertise (Interprofessional Education Collaborative, 2016; Slim et al. 2021) recognizing that each person has valuable input and should have an equal voice. Pat volunteers as notetaker. Bea, as team leader, reviews notes, monitors time, reflects, and summarizes group ideas, and problem solves if conflict(s) arise.
#5 Does the team agree on shared stories of strength?
When trying to build group cohesion, it is helpful to share stories of strengths to motivate the group toward a joint focus on the qualities that make the client a unique and wonderful human being. Each team member can be encouraged to contribute in a way that they are comfortable with—via data, test results, storytelling, or reports from others. If a team member struggles to share a story of strength, other team members can empathize, and revisit documented strengths.
In our scenario, Pat struggles to share. Bea acknowledges, saying, “I hear you. Sometimes it’s challenging to notice small gains when we are worried.” Bea helps Pat revisit Kit’s recent attempt to communicate with a peer at the zoo. A common thread in the shared stories was an increase in motivation and persistence for communication, particularly surrounding animals.
Does the Team Agree on the Plan?
#6 Does the team agree that caregiver contributions and concerns are incorporated into the goal?
This step places emphasis on goals of social significance to the family. If a caregiver is unable to contribute relevant family information and state concerns, use motivational interviewing to reveal socially significant caregiver (stakeholder) values and priorities related to the goal.
Bea, as group leader, ensures that improved intelligibility remains Pat’s priority.
#7 Does the team agree on needs and skills identified?
At this step, team members focus on the unique needs and strengths of the learner. This is a dynamic process based on the development of new skills. If needs and skills are not identified and agreed upon, the team should refer to or conduct indirect and direct assessments.
Members note that Kit’s increase in motivation for attention and ongoing interaction surrounding animals provides new opportunities to shape articulation. In the area of access needs, Bea references Kit’s barriers from the Verbal Behavior Milestones Assessment and Placement Program (Sundberg, 2008) which included: Weak or Atypical Motivating Operations (MOs), Response Requirement Weakens the MO, and Articulation Problems. This information is provided simply, stating, “Kit has a small, but growing group of preferred toys and activities. The team must work carefully at the ‘just right’ challenge level for speech to avoid loss of interest in an activity.” Team members are excited when Sam notes that daily practice opportunities with people who recognize and respond more quickly and vibrantly to better sounding words will improve intelligibility.
#8 Does the team agree on barriers identified?
Barriers such as environment, staffing, equipment, and training should also be identified. If barriers cannot be identified, consult a list of barriers — Applied Model of Interprofessional Collaboration – Assessment (AMIC-A).
Sam suggests they consider team member knowledge, skill, or attitude barriers or system-level issues that may create obstacles to progress. Pat notes that Kit’s father and sister often anticipate Kit’s needs and provide items without language expectations. Members agree that Kit’s XYZ staff and family would benefit from a list of Kit’s best approximations and training on differential reinforcement.
#9 Does the team agree on strength-based teaching strategies?
As team members have listened carefully, together they identify reinforcing situations and teaching procedures that have been the most successful in promoting learning in the past. This information is combined with knowledge of current evidence-based teaching and caregiver and environmental variables which result in evaluating teaching procedures with optimal probability of success. If strength-based teaching strategies are not identified or agreed upon, review strength-based assessments & current effective strategies — AMIC-A.
Kit’s team recognizes his strengths in the love of animals and enjoyment of routines, especially bathtime, snack time, and trips to the zoo. Sam notes that Kit’s ability to produce two syllable words is emerging. The team brainstorms ways to use Kit’s love of animals and routines to promote more practice. They contrive opportunities to request by placing preferred sets of items on shelves, visually available but out of reach. They incorporate specific targets during functional daily activities. Social behavioral play chains that mimic routines are developed. Sam provides two syllable animal names like “bunny” and “kitty” that are a perfect challenge. Bea, Pat, and Kit quickly establish a chain of “animal,” who becomes “muddy,” jumps in the “water” and then dries off on the towel. Sam suggests using “tah-woh” for “towel” and Kit immediately changes from producing a single syllable “tah” to two syllables “tah-woh” instead. All team members are excited by the success of this activity and celebrate the promise of future progress as a result of collaboration.
#10 Does the team agree on data collection and indices of progress?
Measurement of progress and a schedule for determining successful outcomes is essential. Behavior analysts are skilled in the identification of data collection procedures and can add value to the discussion. Importantly, efforts must be made to collect data that will yield sufficient information to determine progress without significantly taxing the caregiver(s) or teammates. A date for analysis of progress and a metric for determining that progress is sufficient to continue the procedure is needed. If data collection and indices of progress are selected and agreed upon, engage in conflict resolution strategies.
Bea offers to collect data on the number of two syllable targets that Kit emits. Sam’s recommendation of a quality measure results in documenting the total target words and targets that matched the best approximation. Sam offers to send a list of Kit’s best approximations.
Does the Team Agree that the Plan Worked?
#11 Does the team agree on the date and method of data review?
Often, electronic data management systems are used by ABA providers, and the resultant graphs can be easily shared. Shared Google spreadsheets could also provide all team members with the opportunity to input and review data. If a date and method of data review cannot be agreed upon, engage in conflict resolution strategies.
Kit’s team agrees to a shared google folder wherein Bea will upload a graph of the targets and Sam will upload the best word approximations. Members agree to meet virtually during Kit’s speech therapy session in two weeks to review the data.
#12 Does the team agree on data review and interpretation?
If precise indices of progress have been identified and data have been collected, the team review of data and interpretation is easily accomplished. For example, a team that cannot convene regularly, could agree to review data with an interpretation provided by the group leader by a designated date and initial to confirm agreement. If data review and interpretation are not agreed upon, engage in conflict resolution strategies.
The team’s goal was to determine if a team approach with precisely selected targets across additional practice opportunities would yield improvement. The team noted improvement in frequency and accuracy of targets. Sam probes the target words as echoics and confirms acquisition of 5/10 of the words.
#13 Does the team agree on acquisition criteria met?
The team collectively consults the data to determine whether or not the acquisition criteria has been met. If acquisition criteria are met, CELEBRATE! If acquisition criteria are not met, assess progress. If progress is demonstrated, growing skills should be celebrated, current strategies continued, and a new review date agreed upon with a return to Step #11. If progress is not demonstrated, the goal should be re-evaluated at Step #6 to ensure social significance and jointly develop new strategies.
All team members are amazed by Kit’s incredible progress in such a short time. They share the joy of watching Kit enthusiastically approach staff, peers, siblings and family members, and hearing Kit’s voice as Kit initiates play. Recognizing the value of interprofessional collaboration is unavoidable. The collaborative team journey has realized greater achievement.
We’ve reached the end of the first leg of a collaborative journey with our fictional characters. Thanks for finishing the drive! With the help of Kit, Pat, Sam, and Bea, our blog aims to provide a roadmap and set of practical tools to help you navigate the complex terrain of interprofessional collaboration. Together, we can overcome the real and sometimes mountainous barriers that we will face on this journey. Interprofessional collaboration requires careful planning, risk, vulnerability, and humility. What we are asking you to do isn’t easy – but the outcome will be worth it. Linger on the benefits of collaboration-enhanced team satisfaction, greater knowledge, and improved client outcomes. So, buckle up and join the ride!
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